AMBULATORY CARE COORDINATOR RN

3 weeks ago

Lexington KY USA, United States Common Spirit Full time
Overview

Job Summary / Purpose

The RN position is responsible for coordinating a wide range of self-management support and disease registry activities for entire populations. Collaboration with physicians, staff and other care team members to improve quality care and outcomes is essential to the multi-discipline approach needed to manage these populations.

Remote with light local travel

Responsibilities

Essential Key Job Responsibilities

* Works with at risk members and families self-management including:
* Setting short and long-term goals for self-management of chronic disease.
* Addressing medication adherence in patients not meeting outcome goals.
* Adherence to Evidence based protocols
* Working with members to create a plan for health behavior change by:
* Assessing and working on the patient's readiness to change, the importance of change, and confidence in ability to change.
* Helping the patient to identify and overcome barriers.
* Refers for appropriate service.
* Performs individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes.
* Providing needed patient education regarding specific health care skills and general disease concepts.
* Facilitates collaboration, communication and coordination among all responsible parties of an individual's multidisciplinary health care team striving to eliminate fragmentation, variation, duplication or gaps in care.
* Assessing and collaborating with clinic managers and directors for CIN practices on strategies to achieve individual clinic goals such as quality indicators and cost-efficiency.
* Understands and self-manages to support CIN-level success goals, including improvements in quality, cost of care and member experience for the CIN's population.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Qualifications

Minimum Qualifications

Required Education and Experience

Bachelor of Science in Nursing.

Required Licensure and Certifications

RN:KY or Compact

Required Minimum Knowledge, Skills, Abilities and Training

* Three years of clinical, community, public health, case management, or health coaching experience.
* Must have strong organizational and time management skills, strong interpersonal skills and the ability to handle multiple priorities
* Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel, Word and Google platforms.
* Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost) for individual users of health care and patient populations
* Ability to work autonomously within a matrix environment without direct supervision or support.
* Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist.

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